How We Diagnose Dementia: The Practical Basics to Know

“Doctor, do you diagnose dementia? Because I need someone who can diagnose dementia.”

A man asked me this question recently. He explained that his 86 year-old father, who lived in the Bay Area, had recently been widowed. Since then the father had sold his long-time home rather quickly, and was hardly returning his son’s calls.

The son wanted to know if I could make a housecall. Specifically, he wanted to know if his father has dementia, such as Alzheimer’s disease.

This is a reasonable concern to have, given the circumstances.

However, it’s not very likely that I — or any clinician — will be able to definitely diagnose dementia based a single in-person visit.

But I get this kind of request fairly frequently. So in this post I want to share what I often find myself explaining to families: the basics of clinical dementia diagnosis, what kind of information I’ll need to obtain, and how long the process can take.

Now, note that this post is not about the comprehensive approach used in multi-disciplinary memory clinics. Those clinics have extra time and staff, and are designed to provide an extra-detailed evaluation. This is especially useful for unusual cases, such as cognitive problems in people who are relatively young.

Instead, in this post I’ll be describing the pragmatic approach that I use in my clinical practice. It is adapted to real-world constraints, meaning it can be used in a primary care setting. (Although like many aspects of geriatrics, it’s challenging to fit this into a 15 minute visit.)

Does this older person have dementia, such as Alzheimer’s disease? To understand how I go about answering the question, let’s start by reviewing the basics of what it means to have dementia.

5 Key Features of Dementia

A person having dementia means that all five of the following statements are true:

A person is having difficulty with one or more types of mental function. Although it’s common for memory to be affected, other parts of thinking function can be impaired. The 2013 DSM-5 manual lists these six types of cognitive function to consider: learning and memory, language, executive function, complex attention, perceptual-motor function, social cognition.

The difficulties are a decline from the person’s prior level of ability. These can’t be lifelong problems with reading or math or even social graces. These problems should represent a change, compared to the person’s usual abilities as an adult.

The problems are bad enough to impair daily life function. It’s not enough for a person to have an abnormal result on an office-based cognitive test. The problems also have to be substantial enough to affect how the person manages usual life, such as work and family responsibilities.

The problems are not due to a reversible condition, such as delirium, or another reversible illness. Common conditions that can cause — or worsen — dementia-like symptoms include hypothyroidism, depression, and medication side-effects.

The problems aren’t better accounted for by another mental disorder, such as depression or schizophrenia.

Dementia — now technically known as “major neurocognitive disorder” — is a syndrome, or “umbrella” term; it’s not considered a specific disease. Rather, the term dementia refers to this collection of features, which is caused by some form of underlying damage or deterioration of the brain.

Alzheimer’s disease is the most common underlying cause of dementia. Vascular dementia (damage from strokes, which can be quite small) is also common, as is having two or more underlying causes for dementia. For more on conditions that can cause dementia, see here.

What Doctors Need to Do To Diagnose Dementia

Now that we reviewed the five key features of dementia, let’s talk about how I — or another doctor — might go about checking for these.

Yours Free: A Cheat Sheet to Ensure a Faster and Better Dementia Assessment. Includes a list of what information to bring to the doctor. – Click here.

Basically, for each feature, the doctor needs to evaluate, and document what she finds.

1. Difficulty with mental functions. To evaluate this, it’s best to combine an office-based cognitive test with documentation of real-world problems, as reported by the patient and by knowledgeable observers (e.g family, friends, assisted-living facility staff, etc.)

For cognitive testing, I generally use the Mini-Cog, or the MOCA. The MOCA provides more information but it takes more time, and many seniors are either unwilling or unable to go through the whole test.

Completing office-based tests is important because it’s a standardized way to document cognitive abilities. But the results don’t tell the doctor much about what’s going on in the person’s actual life.

2. Decline from previous level of ability. This feature can be hard for me to detect on my own during a single visit. To document a decline in abilities, a doctor can interview other people, and/or document that she’s reviewed previous cognitive assessments. I have also occasionally documented that a patient is currently unable to correctly perform a cognitive task that is related to her career or education history. For instance, if a former accountant can no longer manage basic arithmetic, we might assume this reflects a decline from previous abilities.

3. Impairment of daily life function. This is another feature that can be tricky to detect during a single visit, unless the patient is very impaired. I usually start by finding out what kinds of ADLs and IADLs help the person is getting, and what kinds of problems have been noted. This often means talking to at least a few people who know the patient.

Driving and managing finances require a lot of mental coordination, so as dementia develops, these are often the life tasks that people struggle with first.

In some cases — usually very early dementia — it can be quite hard to decide whether a person’s struggles have become enough to qualify as “impairment of daily life function.” If someone isn’t taking his medication, is that just regular forgetfulness? Ambivalent feelings about the medication? Or actual impairment due to brain changes? If I’m not sure then I may document that the situation seems to be borderline, when it comes to impairment of daily life function.

4. Checking for reversible causes of cognitive impairment. I mentally divide this step into two parts. First, I consider the possibility of delirium, a very common state of worse-than-usual mental function that’s often brought on by illness. For instance, I’ve noticed that older people are often mentally assessed during or after a hospitalization. But that’s not a good time to try to definitely diagnose dementia, because many seniors develop delirium when they are sick, and it can take weeks or even months to return to their previous level of mental function.

(My approach to considering dementia in seniors who are confused during or after hospitalization: Make a note that they may have underlying dementia, and plan to follow-up once the brain has had a chance to recover.)

After considering delirium, I check to see if the patient might have another medical problem that interferes with thinking skills. Common medical disorders that can affect thinking include depression, thyroid problems, electrolyte imbalances, B12 deficiency, and medication side-effects. I also consider the possibility of substance abuse.

Checking for many of these causes of cognitive impairment requires laboratory testing, and sometimes additional evaluation.

If I do suspect delirium or another problem that might cause cognitive impairment, I don’t rule out dementia. That’s because it’s very common to have dementia along with another problem that’s making the thinking worse. But I do plan to reassess the person’s thinking at a later date.

5. Checking for other mental disorders. This step can be a challenge. Depression is the most common mental health problem that makes dementia diagnosis difficult. This is because depression is fairly common in seniors, and it can cause symptoms similar to those of dementia (such as apathy, and poor attention). We also know that it’s quite common for people to have both dementia and depression at the same time.

In many cases, there may be no easy way to determine whether an older person’s symptoms are depression, early dementia, or both. So sometimes we end up trying a course of depression treatment, and seeing how the symptoms evolve over time.

It’s also important to consider the older person’s mental health history. Paranoia and delusions are quite common in early dementia, but could be related to a mental health condition associated with psychosis, such as schizophrenia.

Can Dementia Be Diagnosed During a Single Visit?

So can dementia be diagnosed during a single visit? As you can see from above, it depends on how much information is easily available at that visit. It also depends on the symptoms and circumstances of the older adult being evaluated.

Memory clinics are more likely to provide a diagnosis during the visit, or shortly afterwards. That’s because they usually request a lot of relevant medical information ahead of time, send the patient for tests if needed, and interview the patient and informers extensively during the visit.

But in the primary care setting, and in my own geriatric consultations, I find that clinicians need more than one visit to diagnose dementia or probable dementia. That’s because we usually need to order tests, request past medical records for review, and gather more information from the people who know the senior being evaluated. It’s a bit like a detective’s investigation!

Can Dementia be Inappropriately Diagnosed in a Single Visit?

Sadly, yes. Although it’s common for doctors to never diagnose dementia at all in people who have it, I have also come across several instances of busy doctors rattling off a dementia diagnosis, without adequately documenting how they reached this conclusion. (It’s also common for them to hardly document anything in terms of the senior’s cognitive state, other than “confused, didn’t know date.”)

Now, often these doctors are right. Dementia becomes common as people age, so if a family complains of memory problems and paranoia in an 89 year old, chances are quite high (at least 60%, according to UpToDate) that the older person has dementia.

It is a major thing to diagnose someone with dementia. So although it’s not possible for an average doctor to evaluate with as much detail as the memory clinic does, it’s important to document consideration of the five essential features as listed above.

If You’re Worried About Possible Dementia

Let’s say you’re like the man I spoke to recently, and you’re worried that an older parent might have dementia. You’re planning to have a doctor assess your parent. Here’s how you can help the process along:

Obtain copies of your parent’s medical information, so you can bring them to the dementia evaluation visit. The most useful information to bring is laboratory results and any imaging of the brain, such as CAT scans or MRIs. See this post for a longer list of medical information that is very helpful to bring to a new doctor.

Consider who else might know how your parent has been doing and behaving recently: other family members? Close friends? Staff at the assisted-living facility? Ask them to share their observations with you and jot down what they tell you. Share these notes, along with the names of the informants, with your parent’s doctor.

Be prepared to explain how your parent’s abilities have changed from before.

Be prepared to explain how your parent is struggling to manage daily life tasks, such as work, house chores, shopping, driving, or any other ADLs and IADLs.

Bring information about any recent hospitalizations or illnesses.

Bring information about any history of depression, depressive symptoms, or other mental illness history.

By understanding what it takes to diagnose dementia, and by doing a little advance preparation when possible, you will improve your chances of getting the evaluation you need, in a timely fashion.

Yours Free: A Cheat Sheet to Ensure a Faster and Better Dementia Assessment. Includes a list of what information to bring to the doctor. – Click here.

Comments

thank you. My 86 year old mom has been having erratic behavior all of a sudden – after a series of traumatic incidents, such as my dad going into hospice, her caring for him relentlessly, then being hospitalized herself with vertigo, etc. My concern over her meds as well as possible neurotoxins affect from fumigating their house this past fall (ants infestation) has me checking into possible external causes. A very clear and insightful post.

Yes, quite possible that the things you mention are contributing to your mother’s mental worsening. Dementia usually does not come on “suddenly.” Good luck investigating those contributors, and helping your mother get the rest and support that will allow her brain to recover to its best capabilities.

Sounds like my Dad and Therese’s Mom had many of the same symptoms. It took many months for Dad’s doctor to diagnose his Alzheimer’s, It wasn’t until after my Mom’s passing – I guess they were able to hide it (unknowingly) from the world.

There is so much I could write about this article. It’s really interesting to see what is termed dementia, vs delirium. My mother is a very complex case. But what is especially interesting about her case is she has a pattern of having seemingly mental anxiety which is related to an untreated illness. She often has the mental anxiety go away when the cause of the illness goes away. Dad often would side with doctors who would say, it’s all in your mind and she’s get nerve pills to treat anxiety over real symptoms. This happened a few times but she also had some episodes where she was treated for mental illness likely depression and bad thoughts many years ago after pregnancy. So she had a few cognitive problems, like being bad with math since an accident as a child.

Later in life she was addicted that is took nerve pills for many years, also tied to resolvable illness that was undiscovered. In getting off those drugs she took a drug that gave her a debilitating illness that stopped her ability to walk. Hardly at all. So my father and I have to wait on her and get her everything. My dad is very old and my mom is old as well. 90 for dad and 76 for mom.

Without going into to many details. There was known diagnostics and hidden diagnostics made by a psychiatrist. Those hidden things were kept from me by the will of my parents and covered up, or the psychiatrist put diagnosis opinions in his notes without telling my parents. This remained hidden in her record.

Now over the years my mom has seen well over 30 doctors for her physical debilitating illness and she has basically the same results, her nerves are damaged and she will never walk without pain that is extreme. She has burning foot syndrome, likely caused by a side effect from a drug that destroyed not only her life but ours as we are stuck wrung for her. She takes a lot of drugs, some off label to treat the effects of the disease/syndrome. Two drugs she takes are Ativan and also Cymbalta. Cymbalta is being taken at 30mg dose per day. She also typically gets 3 hours sleep per night, and naps at times during the day. Without Ativan she cannot fall asleep if stressed and she’s used to taking the equivalent of four 1mg doses per day. She takes heavy pain mess each day. We are talking Norco and a duregesic pain patch. The pain patch is fentanyl 50mg every three days but was 75 mg every three days before the hospital visit. She also takes lisinopril 10mg a day for blood pressure. The blood pressure is will rise due to pain. Level 7 normally up to level ten during a pain flare. She also has environmental chilling of her feet.

She also is very demanding, but of course a part of this is due to being immobilized in a lazy boy and has a strange setup that took 3 hours to get in and out of to go to the restroom. She has home care givers come to the house. She can’t be in a warm environment for long. She basically has a ton of problems and some come from adapting to the foot peoblem, a result of adapting and doing behaviors to compensate for foot pain or reduce it. For example when you don’t want to spend more than two or three times going to the bathroom because it’s a three hour ordeal you limit your fluid intact. Sitting long hours can cause more problems with your body. The cold air for the feet which burning foot sufferers end up using chills the rest of the body, so you’ll have to bundle up and experience aches and pains. Chilling the room makes our family a bubble house family because the cold air leads to isolation. We have had to feed her special diets and meals because her pain is related to diet as well. Salty and sweet or spices or even hot foods can cause pain flares. She lost her teeth and has to have chopped and chilled food. Some foods set her off.

She had some minor problems she wanted to get taken care of and went into the hospital for those. She can be very demanding. If her Cymbalta is increased to 60mg a day, her requests that are always demanding with Cymbalta added go to 30 requests per minute, even a staff of four people could not keep up with those demands.

She has suffered a mania from lack of sleep before. Sleep deprived for three or four days when overdosed on Neurontin given off label to try to cure her foot problem. She experience sleep deprived delirium and was hearing things. I’m aware of this and saw it. I’ve had a kind of rem sleep delirium myself a kind of sleep deprived rem state where the mind races without sleep or when fatigued a lot. It’s like sleepwalking while your awake. Mixing dreams with reality forming an alternate reality. I have my own theory but just as a normal person, and that is sleep deprivation can drive the mind I to a rem state while awake. Maybe that’s delirium. If you are alert enough you might take notes and even have interesting dream like thoughts that are like a kind of cognitive drawing.

In the last hospital episode she was interested and demanded to go to the hospital for a non emergency, that could be handled by ER but didn’t have to be. I found out relatives who don’t live with us we’re hearing complaints from mom about our not meeting her every wish and filling APS social worker complaints against us as some kind of abuse or neglect charges. Didn’t know who that was. Didn’t know the exact charge as they would arrive, take notes and leave and say the charges would be dropped.

When we got to the hospital mom was dropped off her medication for procedures and some required things like colonoscopy tests. These won’t work with someone who takes three hours to go to the bathroom. Mom was not getting much sleep. And she only got 10 to 12 hours over a week. Her medications were changed and without Ativan her sleep deprived delirium like symptoms and racing mind were happening. And I saw this decline before so I was worried about it.

They were not feeding her enough and she was complaining about everything and not on any one topic, like rem state dreaming while awake. Every complaint was accurate and made sense to me but the topic of context was absent as she would switch topics constantly. I found out that she wasn’t getting Ativan because they were afraid of side effects and could not sleep until she got that. Drugs used for common recovery caused her burning foot flares to move around the other parts of her body, as evidenced by skin temperature readings. The family had to do the medical chilling and I ended up bringing food I made from home in coolers to feed her.

I caught a social worker lying to me, covering up something. I didn’t trust her from that point on. My dad and I were left for a week trying to stay in my moms room and support her care and we were losing sleep.

The hospital made a few mistakes and when my. I’m complained and I started to complain, well we became problems in their eyes. I’m sure of that. They abused her feet when I left her alone and then covered it up in the records. Then they tried to railroad us to a nursing home quickly. And we said we can’t trust the nursing home unless we check it out because you guys aren’t taking good enough care and we can’t trust you. So they gave us a chance to stay one more day for a mental health evaluation. That night I realized mom wasn’t going to ever pass it. Because she had not been getting enough rest and there was no point in testing her mental state she would fail. We decided to leave in the morning and reject care. I talked it over with mom and dad. But we were held against our will with a threat of hospital guards. I didn’t understand why. Mom failed the test and the staff who promised that we could decide if she didn’t pass the test pressed us for a placement into the nursing home because she had dementia and families will not see it and choose to deny it. We agreed. Once in I found that relatives filed for guardianship. Because we had no living will or poa that we could recall and none was signed during admission.

Mom was put in a room that was 84 to 90 degrees hot when she normally is in a 60 degree room with air conditioners and fans blowing over her burning feet.

Dad and I and mom were out of the frying pan and into the fire.

The transport van lady didn’t fasten down her wheelchair and had the heat on High during the entire ride to the nursing home. We had to pay for transport, because they didn’t trust us or that’s the common way things are done. Moms blood pressure was 193/83 from the transport to the nursing home.

We were stuck in legal limbo and the state had guardianship rights over her care and my relative drove up to file for guardianship to take car of mom and later admitted to “save us from ourselves”. Mom was losing more sleep in there and I was as well. My heart felt like it was going to fail. I found that my relative filed for control of 50 percent of our finances, by virtue of the wording.

I ended up asking the nurse to retest mom to find out if she had dementia, stating I didn’t think she had it and that it was a false diagnosis. It she passed the evaluation and was able to sign herself out. I wanted to see the hospital and all medical records to figure out what was going on. What did I find. I found out that my father and I were charged with neglect by my relatives. They were treating us as part of the problem and there were two plans. A public plan and a secret private plan apparently. This private plan was determined to diagnose my mother as having dementia in order to get her out of our care/neglect. The problem was the hospital and nursing home actually cares less, abused her and covered it up. I have absolute proof of this. Everyone in the hospital was lying about this. But the record didn’t lie. The measure,mets didn’t lie. And the evidence and facts I uncovered didn’t lie. What happened was selective half truths were used to frame my father and I as neglecting my mom when medical professionals have said we are the best caregivers they have ever seen. Yer we were being accused behind HIPPA privacy and didn’t see that. We didn’t know but were being tried behind e scenes without any chance of defense. Relatives trying to help us were setting us up and twisting us into a series of catch 22 scenarios. They even lied when making excuses after the facts and never apologized.

I found out the hospital entered a diagnosis into the system before my mom was tested which stated dementia as the diagnosis. A letter was written to the nursing home and signed with lies that mom had dementia as a diagnosis and was treated for It in the past 24 months which is a lie. That she was diagnosed with it, five days before the psychiatrist saw her. She was on three times more blood pressure medication than she normally gets and was losing sleep. Basically dementia was used as an excuse to kidnap my mother from our care. Now I do admit we neglect some of her requests because there are many of them. She has a complex case with many ailments and many drugs being taken. A discussion with a neuro psych clinic person in the phone resulted in them admitting if we went to get her tested we’d never get a proper diagnosis with all the drugs she has to take for her burning foot syndrome. In the backstory of this my relatives decided to make my dad and I villains as we reacted we were attacked through emails and texts saying my dad had dementia as well. That’s just another way to get him in a nursing home as well. Dementia can be used to get guardianship and steal assets from the person. It’s a rising trend by those who have no respect for the elderly or their care.

It’s important to have care givers keep an eye on seniors who might be easily exploited by those seeking to take advantage of them. How did the hospital get involved with this. One of the accusers was a social worker and set us up with the medical workers behind the scenes. So we were tried by a kangaroo jury behind the scenes. And the lies are evident in the records and flaws point not only to neglect and mistakes by the medical system, but a plot and purposeful use of a false diagnosis to take control.

Now I understand is someone is really abusing someone then something has to be done. My point is subjective emotions were manipulated behind e scenes and once the ball started rolling there was virtually no way we could stop it.

This makes me so mad, I’d like to sue the heck out of everyone involved. I even wouldn’t mind going around that and going directly to the criminal court system and file because the conspiracy was so wide ranging end full of lies and bs. The biggest problem I have is my relatives even though they did this would be implicated and it’s difficult to say how far the courts would go. This kind of stuff happens all the time But people don’t have time to figure this out, and would rather move on with their life. The problem I have now is the past medical records could harm her future care. Things written that are false may show up in future records. Everyone has a right to their opinion. I’ve had eight medical professionals say my mom doesn’t have dementia and some claim the doctors and relatives who did this have dementia instead. It becomes a thing that is so difficult to unravel.

I’m ready to write a book about this and almost feel like going for the publishing of the true story in all its details without revealing the actual names. I almost feel new laws like laws to allow patients to have a recording via video and audio of their entire stay which are secured for future evidence needs to be allowed. After all a police officer may have to wear a body cam to document life and death decisions. If a police officer needs body cams to protect him and the citizens, why should a medical professional not wear one. They can be judge and jury and harm or kill you and hide it and hide the evidence.

I feel like we got a taste of socket healthcare instead of US healthcare. Supposedly the patient and his loved ones are supposed to be given truthful information during their care. We got a lot of lies and stonewalling. My advice is beware and get good references before going to Mickey Mouse hospitals.

I would agree that your mother is a “complex case.” In particular, it can be hard to diagnose dementia in people who take a lot of potentially mind-altering medications. Also true that sometimes there isn’t a lot of transparency when it comes to diagnoses or medical information. I hope things get sorted out — or at least improve a bit — soon.

My mother fell two months ago and fractured six ribs and hit her head. She is 93. The hospital took X-rays, told me to take her home and give her some Advil. I was flabbergasted. Shouldn’t they have kept her overnight at least because of her head injury? Now she has started scratching her head saying there is some kind of cradle cap on it. She has dug sores in her head and is losing her hair. We took her to her Dr. he ask her if it itches and she says no. He prescribed Zanex .5 for her nerves. She is still scratching. Could this be caused by something else????

Digging sores in her head sounds concerning. She says it’s not itching: what reason does she give for her scratching? It sounds like she might benefit from a little more investigation from a clinician, to figure out what is driving her head-scratching behavior.

Xanax is a benzodiazepine sedative/tranquilizer drug. Like all benzos, it’s on the Beer’s list of medications that older adults should avoid or use with caution, because benzos tend to worsen thinking and increase fall risk in people your mother’s age. As a geriatrician, I only use benzodiazepines as a very last resort, when all other options have been considered and if we decide the likely benefits outweigh the risks.

So I would recommend you follow-up with her doctor and ask more questions. You may also want to consider a second opinion from a geriatrics clinic, a dermatologist, a geriatric psychiatrist, or just another generalist physician (preferably one who is careful and thoughtful).

Last but not least: Advil is also on the Beer’s list of medications to use with caution. Unfortunately, it remains common for doctors to prescribe risky medications to seniors, without having discussed risks and alternatives with patients and families. So keep asking questions and doing your own research, as you are doing. Good luck!

My mother just celebrated her 75th birthday but had a lot of trouble remembering how old she was. You stated that although it’s common for memory to be affected, other parts of thinking function can be impaired. Do most nursing homes offer memory care or options for patients with dementia?

I didn’t read anywhere that you ultimately refer the patient to a neurologist specializing in dementia. My father had Lewy Bodies dementia. Is a primary care physician qualified to solely diagnose dementia. I would argue that they are not. My father died prematurely because he was not properly diagnosed and was prescribed medications that adversely affected him. Had he been referred to a neurologist specializing in dementia, he would not have been prescribed this medication, and he would have died from a natural progression of the disease. He was a victim of a primary care physician, who was too arrogant to admit that they were not qualified to solely diagnose dementia thoroughly. Do you not see this as an obstacle to adequate care?

In many cases, a primary care clinicians should be able to make a preliminary diagnosis of dementia. Now, in this article, I don’t go into the additional issues that PCPs — or any clinician — should check for once they conclude an older person likely has dementia. But actually, checking for hallucinations and signs of Parkinsonism would be among them. Such features are common in Lewy-Body dementia, and do indeed mean one should avoid medications that interfere with dopamine in the brain.

Whether to refer to a neurologist or specialist depends on many factors. If a patient or family has any concerns, it’s certainly reasonable to ask for a second opinion or a specialty consultation. But specialists don’t always get things right. There is probably no substitute for doing a bit of one’s own research, as this helps one prepare to ask better questions.

A separate but related question is, to what extent is it important to have the underlying cause of dementia identified? I think PCPs should be able to diagnose dementia, but determining the underlying cause is indeed much harder. In people who are older than, say, 80, I don’t particularly try to identify the sub-type of dementia. That’s because mixed dementia becomes very common as people get older, and I don’t find that it’s useful (meaning helps me better care for the person) if we get specialty consults to try to identify the underlying cause.

Instead, I think it’s important to check for certain features that will affect care, such as visual hallucinations, parkinsonism, or other signs of Lewy-Body dementia. Again, this is because such features means it’s more important to be careful about certain types of medications.

It is also important to inquire about what types of difficulties a patient or family is encountering, and then create a care plan that addresses those. There can be a lot of variation in symptoms within a type of dementia. Now are PCPs equipped to deal with this? Probably not, but they need to get better. In the meantime, it’s multidisciplinary dementia clinics that are best, because they usually have nurses and social workers who are trained to help families with common challenges.

In short: I agree that it’s risky to solely depend on PCPs for adequate dementia evaluation and care. But referring everyone to a neurologist is probably not the answer. Instead, we need for PCPs to be better trained, families need to be ready to ask a lot of questions, and most of all, we need more dementia clinics that are equipped to help families with the many common challenges they will encounter.

My 73 year old mother has thought (feared) she’s had Alzheimer’s for about 6 years. Just last week she saw a psychologist to take screening tests to check cognitive function and memory. She scored below (mildly) normal aging memory problems. She is also had ADD, anxiety and lately had suffered some depression (as she’s lost all three of her brothers and her mother in the span of 5 years, two of them died 3 days apart, also a close sister was diagnosed with Parkinson’s and best friend with cancer, also was dealing with her mothers Health issues) she had gone off her anti anxiety medication for about a year all on her own. We got her back on it in April and she said she has been feeling a lot better. We’ve all noticed improvement but still memory issues and also confusion at times. We know when she took that test she was super nervous, and as my dad said, “crumbled” while being asked questions. He knows that she could answer some of them while not under the pressure and fear of taking the test to semi diagnose for Alzheimer’s or dementia. We will be getting full blood tests done, checking for thyroid issues and b12 Deficiencies, also I think it’s so important she checks in with a psychiatrist to adjust or check her prescription for anxiety medication to see if it’s still the correct Dosage and/or medication. I believe it has been MANY years since she’s seen a psychiatrist for medication.
So, my question(s) are…. is it possible for someone to show many symptoms of early Demetria/Alzheimer’s and the cause be solely depression and/or side effects of medication? She has trouble with numbers (although math was NEVER her strong suit) and remembering dates, etc. she gets a little confused at times, forgetful (but not horribly), she had forgotten how old I am …just knew general age. I’m just wondering if these signs could be a cause of a lingering depression that’s been undiagnosed for years? Her symptoms have gotten worse, but mildly worse. And like I said, she got really bad last fall after two family deaths back to back and then improved after getting back on anti anxiety meds. Although I’m still not sure this is correct dose for her now, or even best medication as I think her needs and other things may have changed with age?)
Would depression or side effects to meds mimic THAT closely Dementia?
Thank you.

For people your mother’s age, I have found that it’s very common for depression or stress or grief to make brain function worse.

That said, I’ve also found that it’s rare that people with such symptoms (and of this age) are otherwise entirely cognitively normal. Usually further evaluation suggests that they either have underlying mild cognitive impairment, or underlying dementia (often very early/mild stage).

There is a concept related to brain function that is called “cognitive reserve.” Basically, a younger or healthier brain has extra processing power, so even if it’s impaired by stress/grief/medications, thinking and memory will remain pretty good. Whereas a brain that has developed damage due to very early Alzheimer’s (or a variety of other problems) will have less reserve. So it takes less stress for the person to become noticeably worse in their thinking.

In short, I think you are right to suspect that the other factors are playing a role in your mother’s symptoms, but there’s still a good chance that her brain is not entirely normal and healthy for her age.

Regarding anxiety and anti-anxiety medications: anxiety certainly makes a person’s thinking worse, so it’s important to help her find ways to manage that anxiety. However, one of the most common classes of medication used for anxiety is benzodiazepine drugs, such as Xanax and Ativan. Those do help with anxiety but they also impair mental function. So I generally recommend that older adults be very careful about relying on those long-term, especially if they’ve had any memory concerns. I have more information here:4 Types of Medication to Avoid if You’re Worried About Memory

She is taking celexa, which is classified as an anti depressant (I read it’s sometimes used to treat anxiety as well…although I feel those two often go hand in hand) I didn’t see any side effects listed that would cause confusion or memory loss though. Do you know anything about Celexa ever causing those symptoms?

Citalopram (brand name celexa) is indeed an antidepressant, of the SSRI class (selective serotonin receptor inhibitor). SSRIs do have anti-anxiety effects.

Citalopram and sertraline are actually a top choice for geriatricians, if we need to treat depression or anxiety in an older person. SSRIs are generally “well-tolerated” and studies have found citalopram and sertraline, in particular, have fewer drug interactions than the other SSRIs, and also tend to have fewer side-effects.

I would not expect citalopram to cause any significant confusion or cognitive worsening.

However, you should know that pretty much all antidepressants — including SSRIs — are associated with an increase in fall risk. In many cases, it still is reasonable to continue with the SSRI, especially if anxiety treatment with cognitive behavioral therapy isn’t a feasible option. (Psychotherapy works when people stick with it and have a decent therapist.) That’s because the benefits of helping the person with their anxiety — esp if the med seems to be working — often outweigh the concern about fall risk.

I think it’s good that you’re planning to have a clinician re-assess your mother’s medications. Good luck!

Hi
My wife (age 62) was asked about 4 months ago to obtain a medical evaluation for problems with her memory at work. There are several things that are making an evaluation of the cause of her symptoms difficult. She is a computer programmer and seemed overwhelmed. Her employer sent a letter written by a non-medical person that said she was exhibiting signs of early Alzheimers because she sometimes forgot her password and asked a lot of questions. We feel that may have biased the primary care MD and neurologist not to fully investigate other causes. Just before this happened, she was starting to finally get treatment for untreated, severe generalized anxiety disorder and just started a small dose of Lexapro. The psychiatrist that interviewed her also said that she also had untreated PTSD stemming from witnessing a fatal shooting at close range. She has had symptoms of anxiety for over 30 years. Sometimes it is better, sometimes it is worse but it has been there as long as I have known her. (We have been married for over 30 years) The incident with PTSD happened over 30 years as well. She also has untreated sleep apnea first diagnosed over 30 years ago as well. She says that the CPAP mask makes her claustrophic and she won’t wear it consistently. She started the assessment for memory loss with the primary care doctor and a referring neurologist. Based upon one MMSE (25/30) , a CT Scan (which was normal) and a MRI that showed some atrophy (we are not sure where) she was believed to have early onset Alzheimers and he was prescribed Namenda. He does not have trouble with grooming, driving, getting lost, knowing the season or date or any of the other symptoms usually associated with Alzheimers. If she is nervous he searches for words but again but can usually remember things minutes later. She has always had severe test anxiety. She almost did not graduate from college because she was afraid of a required test. So these symptoms have gone on for years. Because we wanted a more thorough evaluation, she is now being evaluated through a university memory clinic. She was extremely nervous during the Mini-Cog (given by a medical student) and didn’t score well. For example, she stumbled over the serial 7s but did it perfectly when we left the clinic. We also have a 22 year old son with schizophrenia that has caused upheaval at home. He is now in a treatment facility but is still a handful to deal with. The university has ordered a sleep study, PET scan, and blood work. I know that she could have age related dementia (which I know is not reversible) on top of cognitive difficulties with anxiety, PTSD and untreated sleep apnea (which may be reversible). But before she is labelled as having cognitive deficits due to Alzheimers, do you think she should have these other conditions treated ? What would be a suitable length of time to tell whether the memory loss is really from these other factors ?

62 is young for dementia. I think it’s good that your wife is now being seen at a university memory clinic, they should be able to do a more in-depth investigation. Normally such clinics will also perform (or refer for) in-depth neuropsychological testing.

It is really common for people to do cognitively worse when they are anxious, and evaluating people like her can be tricky.

Whether or not she might have an underlying problem such as Alzheimer’s, it’s important to treat everything to the extent that you can, because you want her to be able to think her best. I would especially recommend you look into non-drug treatment for anxiety, as many of the anxiety drugs (especially benzodiazepines) tend to make cognitive function worse.

In people your wife’s age, whether or not they have Alzheimer’s often becomes clearer over time…people with Alzheimer’s will tend to get worse over the coming year, whereas cognitive impairment that is not due to neurodegeneration often remains stable or even improves.

I would recommend you request and keep copies of all lab results, radiology results, and so forth. This will make it easier to get a second opinion or do your own research.

Good luck sorting it out. I especially hope your wife will find ways to alleviate her anxiety and feel ok despite all the health and life challenges she is facing.

Hello, if I may, I need to ask for advice. I apologize in advance if I’m not clear enough. I’ll try to tell as much as I can without repeating myself.

For about a year now, my mother has been displaying a lot of erratic and uncharacteristic behavior. She’s talking to herself (not in a “thinking out loud” way, but more like a whole conversation), occasionally sees things that aren’t there, has reported hearing noises, such as birds chirping or running water, when at the time there are no such sounds occurring, or at least aren’t heard by others. She’s also been accusatory and agitated. She accuses people (myself included) of theft, of controlling her, forcing her to do things, or wanting her dead. I don’t want her dead, nor does anyone else in the family, nor her friends. Mom is also confused a lot. She has forgotten things like the date, my age, my weight (that’s another topic though), the date, and whether I’m married with children (I’ve never been married and don’t have any children.) and is swearing rather frequently, including inside stores and even around children. “Swearing like a sailor” as the saying goes. I know that a lot of people do swear, and she has sworn before, but never to this extent, if that makes sense. Mom has also been saying that people are doing x, y, or z, when said thing has either never happened, didn’t happen the way she said it did, or involved other people instead of her.

Mom never set up legal aid, like power of attorney or anything. She believes that “it would give someone else control over her life.”

I would speak to her doctor, but she retired a little over two years ago, and that was before all of this began. She refuses to get another doctor, and believes that she’s okay. Mom also gets mad anytime someone even mentions doctors, and has also said things like “You can’t control me!”, or “You just want me dead!”, or “You’re after my money!”

If you ask her about one of her “moments” (for want of a better word), she thinks that nothing happened; she didn’t say ____, didn’t do ___, etc.).

I know that I cannot force her to see a doctor, and I don’t plan on trying, but I feel that I’m getting to my wits’ end. I don’t want to jump to conclusions, but I worry that she has some form of dementia.

Is there any way I can get her to see a doctor, and find out what’s going on?

Well, you don’t say how old she is, but I agree it sounds worrisome. The things you’re describing are not uncommon in the earliest stages of dementia. But, they can also sometimes be caused — or worsened — by other health issues, such as medication side-effects, or electrolyte imbalances.

Some of the false beliefs, hallucinations, and suspicious thinking you describe fall into the category of “late-life psychosis”, and I explain the most common causes here: 6 Causes of Paranoia in Aging & What to Do.

In the article on paranoia, I also cover some of the ways you can try to get help, when the older person is refusing to see a doctor. Sometimes it’s possible to persuade a person by bringing up some other aspect of their health, you would have to see what kind of reason might seem persuasive to her. Otherwise, if things get very bad in terms of how an older person manages their home, family sometimes calls Adult Protective Services.

It is a difficult situation. Try to avoid arguing and reasoning with her and instead try to be reassuring. Good luck!

Another possibility would be to see if you can get a health professional to visit and assess her at home. You would have to see if that type of service is available in your area, and you might have to pay out of pocket for it.

Although she doesn’t have a diagnosis, since her symptoms are concerning, you could try calling your local Alzheimer’s association for advice on how to get a reluctant older person assessed. Good luck, it is a difficult situation.

My father will be turning 83 this year and we have noticed changes including not remembering to take his medication (cholesterol, diabetic, aspirin as well as glaucoma eye drops). Thought we worked on a good system but noticed that he was either not taking at all or maybe more than once in a day. Here is some notes I took with me to the neurologist appt. Phone conversation with Dad when he was in Florida (lived part year in Florida) mentioning that he had been driving around a lot and had been in Texas and Alabama, but I knew he never left Florida. Was told by close friend in Florida – he tried twice to pack up his Ford F250 and leave Florida to drive to New Jersey. Thinking New Jersey was 4 hours away (Dad is a retired truck driver). The friend took keys from him after taking ride to Walmart shopping center with him and Dad not knowing how to get back to trailer park. Flew from Florida to New Jersey on May 5th, friend took him to airport and then got a security pass to take him to gate. Arrived in New Jersey and I met him at security desk. He had called my brother on cell phone to tell him he arrived as he thought he was picking him up. Didn’t recognize my car. Have had the car since 2011. Talked to me in the car about coming up through Virginia as they had to take a different path because his boss had spies watching them. At my house brought in his luggage and about 3 hours later he asked if we needed to bring in luggage. Unpacked his luggage and found that he did bring the Metformin with him but not Lisinopril, baby aspirin or Simvastatin nor Cosopt or Latanprost, or his shaving gear or deodorant but packaged bath towels, curtains, and rags. I did have back up of medication since it seemed he wasn’t taking the correct dosage. Had hoped I had him back on schedule when he left the end of February to go to Florida. Sunday morning, I saw he took his medication and eye drops but I ran to CVS later that evening and when I came back he told me he took his medication. Don’t know if he took it twice or not. For Mother’s Day went to Harrah’s Chester to the steak house and did some gambling afterwards. His sister-in-law came up to me about 10 minutes after we arrived to say that instead of using player’s card for the machine he asked her if he could use this card, which happened to be his debit card. She had him put it away in his wallet and retrieved his player’s card instead. I spent the rest of the evening with him. He also left me to go to cashier to cash in ticket. Was supposed to come back to me but ended up in an entirely different area but found his other sister-in-law and she called me to say he was with her. Saw a neurologist and the memory test scoring was a 13 out of 30. Mentioned Alzheimer’s. Ordered a MRI and blood work. MRI conclusion: No acute intracranial abnormality on non-contrast MRI of the brain. There is advanced chronic small vessel ischemic disease of the white matter. There is advanced atrophy and venticulomegaly. Have a follow-up appointment coming. Can you give me feedback and direction of questions to talk to neurologist about?

Sorry for delayed reply. His symptoms sound concerning and consistent with dementia. The MRI is suggestive of a vascular dementia component. Mixed dementia is very common in older adults so he may have a combination of Alzheimer’s and vascular dementia.

You could ask the neurologist to clarify if there is any signs of Lewy-Body dementia. This matters in that people with LBD tend to be quite sensitive to certain types of antipsychotics (should they ever become necessary to manage behavior, which hopefully won’t be the case as they are supposed to be used as a last resort).

Otherwise, I would recommend connecting with the Alzheimer’s association or some form of dementia support group. You will need to process the diagnosis, figure out how to support your father, and especially start planning to manage his care now and in the future. Good luck!

Why diagnosing Alzheimer’s today is so difficult—and how we can do better

I can understand the current concern with glucose metabolism in the brain and possible damage, however, in a brain that is glucose deprived, astrocytes in the brain also generate ketones that can be used by neurons. I think a more precise if not accurate measurement would be to measure the rate of adenosine triphosphate (ATP) production. ATP levels fluctuate depending on brain activity. This may be beneficial in determining abnormal brain activity or neural activity at the molecular level. Calcium, sodium, and potassium ions continuously passed through the membranes of cells, so that neurons can recharge to fire. ATP supplies the energy required for these ions to traverse cell membranes. An imbalance of these ions can cause swelling, damaging cells leading to strokes and possible the disease process of Alzheimer’s.

This brings me back to the importance of measuring Calcium, sodium and potassium levels and their relationship to ATP levels and ultimately the development of amyloid plaques caused by astrocytes themselves. The amyloid plaques that accumulate and can cause neuronal loss and damage have been reversed to a degree in mice by reducing beta-secretase. I think this may be a promising treatment in the near future along with other advances in the progression of the disease process.

Thanks for commenting. Yes there is a lot of interesting basic science research being done on the pathology of Alzheimer’s. The kinds of measurements you describe might be relevant for research purposes — or for clinically testing interventions applied during the early pre-symptomatic stage of Alzheimer’s — but right now are not applicable to the clinical evaluation of older adults with memory impairment or other cognitive complaints.

Hello
I don’t even know where to begin..my 87 year old mother has always lived in denial for many things throughout her life. I believe that’s her defence mechanism for stressful things raising 6 kids. She has been active and healthy until complications from a femoral bypass 2years ago left her with a terrible infection that finally made it necessary to remove her leg. This woman fought colon cancer at 83 and came back stronger than ever after having all but 8 inches of her colon removed. My brother had colon cance at the same time as well as esophageal cancer (he was also in remission for non Hodgkins.
I say this because I want to show a picture of her stresses.
Last year, 2weeks after mom had her leg removed (was home from the hospital on day 4 because she did so well!) my alcoholic sister died suddenly. She mentioned to me a few days earlier that she thought my sister was coming in her house though a window and sleeping with my mom’s partner. When I went to tell her that my sister had passed, she s remedies to not hear me and said “b” her partner was in napping for a long time and I think “D” is in there with him. My husband and I couldn’t believe what we just heard, I had to be firm with her and explain that D was dead. The very next day, I had to break the news to this lovely woman that my brother had succumbed to cancer, right after we told him about our sister. (He was dying from oral cancer His 4th cancer..he was 62 and my sister was 61.

I’m sorr this is long. Mom has believed since all of this that someone is concerned Ming in her house and using her things, sleeping under the bed, eating her food. One tine she called me at work because half a banana wa gone and she asked if I ate it. Her partne4 is fed up and I believe helps to “feed” her paranoia by saying things like “ yes, my girlfriend can drive my car but you can’t”. I had a geriatric dr assess her when she was just n rehab for her leg. The social worker was shocked when I was old her this..she said she never would have guessed because she spent a lot of time with her and saw a youthful, vibrant go getter. The cat scan came back “normal for her age”. The said she doesn’t have hallucinations but delusions and seems to be in denial. They wanted to put her on risperadol but when she saw that it was written down “to stop hallucinations, she would not have anything to do with it and told me she would not be sharing anything with me again.

She was better for a while and is walking with a prosthetic..now the paranoia has returned and she is not holding back like she did…she is leaving notes in her drawers saying “keep out whore” and making notes of everything that is missing.

I should add that recent blood work shows decreased kidney function and liver problems. And her diabetes is out of control
She will not go back to the geriatric dr because she was “labelled”. I don’t know where to turn now…her family dr is retiring and gas neve4 been much help.

Sorry to hear of your mother’s difficulties. I can certainly see why you are concerned. Given her age and the health problems you describe, her paranoia probably reflects her brain malfunctioning due to lots of reasons happening at the same time. It’s pretty common for people to have some small vessel changes to the brain by age 87, especially if they have diabetes, plus she might have some other health issues that are worsening this as well.

Re how to behave with her, you might want to tell her partner that trying to reason with her or bring her back to reality generally doesn’t work. He doesn’t have to agree with every false thing she says, but it’s usually possible to diplomatically address the emotion and provide some type of validation and reassurance. That is what she needs the most, a reassuring emotional connection and also a stable routine and environment.

Antipsychotics such as risperidone sometimes help with florid delusions and paranoia, but they almost never make an older person “normal”; it’s more that they can take the edge off the worst of it.

It is definitely hard to get someone like your mom to the doctor. I offer some suggestions in the last part of the paranoia article linked to above. Good luck!

Hi, I have believed my Mom, who will be 84 in December, has been experiencing dementia for over two years. She had been under a lot of stress with caring for her husband due to Parkinson’s. He passed away in August 2017. We had hoped her memory issues were the result of stress but they continued to get worse. In late June 2018 she moved to a home closer to us (eight doors away). People who do not see her every day do not realize she has issues. Some of the examples are: she drove to an airport which should have taken no more than 1.5 hours. It took her over five hours to arrive and she never called any of us for help. She keeps calling things the wrong name i.e. calls the microwave a computer; calls the kitchen island a work bench; calls the bar (where you sit in a tavern) “the bench”. She forgets words and may or may not come up with the word(s). I call her every night on my way home from work. She can tell me the same thing three times in a 15 minute call. She has to write herself detailed notes, often, and still forgets. She has difficulty balancing her checkbook. Could take her hours to days to figure it out. She has problems comprehending what she reads. Recently prior to having surgery they provided her with things to do to enhance her recovery. She made four copies and read the material dozens of times; marked up the copies with highlights, underlining, circling, notes on the side and she still did not correctly follow what they wanted her to do. One of the things was if she was taking two types of specific medications she needed to stop taking them a few days prior to surgery. Instead she quit taking ALL of her medications cold turkey for six weeks, including the newly prescribed and filled medications to help enhance her recovery. Two days after surgery they gave her a little test. She answered everything correctly except for who is the president of the United States. She told the doctor it was Nixon. The doctor believes she has early onset Alzheimer’s dementia. Her older sister also has it. Her primary physician saw her today and said she has been under a lot of stress and will wait awhile and see how she does. Your thoughts? Thank you

Sorry to hear about your mother’s situation. Her symptoms do sound concerning, especially since it sounds like they’ve been going on for quite some time. Stress will make her worse, but it sounds unlikely to me that only stress would be causing this.

Doctors do sometimes want to wait and see how things evolve, although that is often because we see people and we don’t have a knowledgeable informant available who can tell us how things have been going and changing for the past 2 years. Also possible the doctor wants to wait if her cognitive tests are borderline. But then again, the symptoms you describe sound pretty significant, and unfortunately pretty typical for dementia.

It’s still important that she have a careful medical evaluation for other causes of cognitive impairment; sometimes medications or other health issues are making people worse than they otherwise would be, and if the brain is damaged, every little thing you can do to improve the function is important. I describe the evaluation in more detail here: Cognitive Impairment in Aging: 10 Common Causes & 10 Things the Doctor Should Check.

This time while waiting for a diagnosis can be very stressful for everyone. Good luck to you and your mother.

Just recommended this page as the best first-place-to-go for everyone with a memory concern. Thank you for your commitment to helping us make better medical decisions for our family members and ourselves. Your thoroughness and compassion comes through in every one of your articles and podcasts. Thank you for sharing your gift with the world!

My parents are worried that my grandmother might have early stages of dementia. You provided a lot of great tips. I loved your suggestion about writing down behaviors and issues that are worrisome. Bringing these documented problems or issues to a neurologist might help the doctor when it comes to diagnosing an issue.

Hello. My mother just turned 88 last month. She was widowed for the second time March 2017. Caregiving my step dad depleted her but she has “bounced back” so to speak. What concerns me are several changes I see: In July 2017 I found out she had a male friend staying at her house, not by her telling me, but by a neighbor. I have met this fellow, as well as my 2 grown daughters, and none of us feel comfortable around him, for many reasons and experiences. My mom says “the good outweighs the bad”, which concerns me. For the past 2 years she cries more easily. For example when her recipe wasn’t turning out, and over who is eliminated on Dancing With the Stars. She didn’t used to cry over things like that. She is forgetting words, can no longer give me directions if I ask her where to go, and sometimes just seems a little “blank”. We have always been close. Now I have found several times where she’s lying to me or keeping things from me. I have been doing a lot of reading, I have the book by Virginia Morris you suggest. I have met with a consultant, talked with her lawyer and taken care of other business. I can’t shake my uneasy feeling. I’m half way across the country, and an only child. It’s agony. Any suggestions, insights? Thank you for this blog!

Well, what you describe does sound potentially concerning. The ideal would be for her cognition to be evaluated, and also for you to try to ensure she isn’t too vulnerable to financial exploitation. Both are easier said than done. Regarding her cognition, there’s a whole medical aspect to the evaluation but the health providers will also need information on what she is struggling with, and how it has changed over the past few years. I have more details here:Cognitive Impairment in Aging: 10 Common Causes & 10 Things the Doctor Should Check.

To help with the agony and uneasy feeling:
– could you go stay with her for 1-2 weeks, and carefully observe the situation? It might help to see if you can get specific about what is off.
– Can you have the consultant — or someone else with suitable expertise — meet your mom and weigh in regarding how concerned you should be?

Unfortunately, the current software being used for the site does not allow us much flexibility in organizing comments. We will probably eventually move to a different system, but it’s expensive and time-consuming to do so.

Is it possible a motorcycle accident 40 years ago has put my mother into an early (she’s 65) stage of multiple types of dementia? She’s functioning mostly ok she still works but she prefers to sleep most of the time when she is home or just watch TV or be on Facebook consuming herself with what is wrong in the world. She’s very hostile she only gets along with people if they have something to offer her and if that stops she accuses them of anything like being greedy or using her and stealing from her (she called me at work to accuse me of stealing a hope chest full of Target Christmas dishes (nothing fancy or expensive) because she couldn’t find them after not seeing them for almost a year). She has always trusted me with everything and I’m always there for her when she gets sick or has a surgery I’m her youngest of 4 kids and I care so I am her nurse if she needs it. I just don’t know what is going on if it’s because I still live with her (I pay most of the mortgage it benefits us both) we have opposite shifts so rarely see each other but when we do she is fast at yelling at me for something/anything. Or if she is truly showing signs of a mental health issue. Her doctor that we both shared was helpful to talk about things I notice with mom but she retired almost 5 years ago and her current doctor is retiring too so nobody is following up on how she is after having a mini stroke several years ago. Maybe she is fine and I’m just worried for nothing and just need to leave her alone and go off on my own life like the rest of my siblings have. But I worry because she wants to retire and sell the house we have struggled for so long to keep in the family and drive around the country just her and her dog like the free spirit she always wanted to be in the 70s before the motorcycle accident and before having kids. If you have any insight I would appreciate it and am open for anything even if it will hurt my feelings that’s ok I just need to hear a perspective different from family.

Sorry if things are becoming more difficult with your mother. If she had a head injury years ago, that can make the brain more vulnerable and is associated with an increased risk of cognitive problems.
It’s not clear from what you describe that she has developed significant memory and thinking problems, but it sounds like her personality is becoming more difficult and perhaps she’s becoming more suspicious of you. This could be caused by mental health issues (some of which can be related to having very small strokes in the brain) or could be due to other changes in the brain or even other physical health problems.
Honestly, she needs more medical evaluation. I hope you can help her get it sooner rather than later, because if she becomes more suspicious, paranoid, or confused, it will be even harder to get her to see a health provider. I have more here:6 Causes of Paranoia in Aging & What to DoCognitive Impairment in Aging: 10 Common Causes & 10 Things the Doctor Should Check
For help coping with your worry and with the stress of living with her, I would recommend seeking out an online support group. There is a very active forum at AgingCare.com, where you can get ideas and also encouragement on how to set reasonable boundaries and think of your own needs while still trying to help your mom. Good luck!

Hi,
I have been having a difficult time with my husband who is 62 years old now for the last two and half years. Our lives have changed drastically. His personality has flipped for the worst. In 2016, he accussed me of having an affair in 2013 again. We dealt with this problem, and I thought it was over. So, I was totally confused. All I could do was cry. During this time, he would say things then he would tell me that he never said them. By the time February 2017 rolled around, he forgot my girlfriend of 33 years. In the moment, he could not remember her and he was totally confused. That is when I realized that something might be going on. I started to notice changes in him. He would mix up names including our children, he would leave our garage door open and the house unsecured, he mixed up things in church, and he continued with accusing me of having an affair. He is delusion. The way he processes information is not normal. He has moved out of our home which is against our spirtual beliefs. He is a Pastor in our church, and he forgets the words when he is singing in church. His friends are starting to notice changes in him. He has shared with his friends that he writes notes to remember, but he cannot find the notes. To make matter even worse, my children are starting to realize that something is going on with him. He is constantly getting dates and conversations mixed up with them. I have been trying for a year in a half to get him to go to the neurologist. His internal medicine doctor ordered a CAT Scan in June 2017 and that came back normal. He was told to go to the neurologist after the CAT Scan. He went to the Neurologist and took the memory test and left. He never saw the neurologist. He scored a 27 on the test. In March 2018, he went back to the neurologist alone, and called me to say that nothing was wrong with him. I don’t know if he took another memory test. Then, April 2018, he was diagnosed with coronary heart disease. Last month, he loss consciousness in his place alone. Then, three days later, he had a severe headache. Both incidents sent him to the ER. After the second ER vist, they referred him to the Neurologist and for a CAT SCAN. He did not go to the appointments. My daughter had a talk with him about all the problems, but he assured her that he is going to the doctor and nothing is wrong with him. My question to you is how do you get someone to go to the neurologist who doesn’t think anything is wrong? He is so stubborn, and I am worried that something serious is going to happen to him. I just don’t know what to do. Any suggestions.

Sorry to hear of your situation, it sounds very difficult. Well, given all the changes and problems you describe, it does sound very concerning and I can’t imagine that he’d be told “nothing is wrong” after a careful history and exam. (In fact, an appropriate evaluation should solicit information from family and others, because impaired older adults are notoriously poor reporters of their abilities.)

There is unfortunately no easy way to get someone to go to the neurologist when they are reluctant or convinced everything is fine. Some families still manage to coax the person to go. Some are able to get the doctor to ask the person to come in; whether the older person complies with the request is variable. Some resort to some deceptions and/or white lies to get their loved one to the doctor. Some hire a doctor to come to the house and do the assessment, but it’s not always easy to find a qualified health provider to do this.

It is usually easier to find a geriatric care manager to hire and come to the house; they are not physicians and cannot make the diagnosis, but they often do have ideas about what can be done to move the evaluation along and address safety issues.

I also recently heard of one man who was finally able to get his older father to the doctor because the father’s driving was reported to the DMV, and he had to get a medical exam in order to potentially keep driving.

In short, you have to keep trying various things. I generally recommend trying to connect with others who have been through this, which means either other family caregivers (there are online communities) or a geriatric care manager. You could also try contacting your local Alzheimer’s Association, they have a support line and may be able to give you suggestions. Good luck!

My dad has hepatic encephalopathy due to end stage liver disease, he is currently listed for transplant. He also has diabetes. He has gone through several episodes that have hospitalized him over the course of the past year and a half. With each episode, he takes 3 steps down and recovers 2 steps in mental function. His daily life has been significantly impacted by this condition. He can no longer buckle a belt, work a faucet, he can’t reliably run phones, or electronics. He no longer manages his finances, and is now living with us as he is no longer safe to live alone. He left a bowl of oats on the gas stove and went to bed, and he has slept for 24hr at one point. He is now losing the ability to dress and toilet himself, he cannot administer his own medications or test his sugar. When Dr.’s talk to him, he can talk a good game, he can pull the date out of the air, and he can sound competent to them with the ability to laugh and joke around with them. But in the same day, he can get mixed up and pee in my clothes hamper, or walk into the pantry thinking it’s the bathroom.

We have reached a point where we will need to provide him with some kind of health aid care while we’re at work. It’s thousands per month and exceeds his monthly income. We are not able to pay this. He owns a house and has some savings, but is not willing to part with it. I don’t think he is capable of making the proper decisions to liquidate these assets to provide care. Would trying to obtain a dementia diagnosis be reasonable here?

Sorry to hear of your father’s situation. It sounds to me like you are concerned about “self-neglect“, meaning he’s living in a way that you think puts his health and safety significantly at risk. Also sounds like the main reason he is impaired is his end-stage liver disease and hepatic encephalopathy, rather than a permanent and progressing neurodegenerative condition such as Alzheimer’s dementia.

Self-neglect is usually pretty challenging, as it’s often hard to determine at what point it’s justified for the local court to override an older person’s autonomy and enable someone else to make decisions. If you are worried about his decisions, I would recommend bringing it up with his usual health providers and also learning more about how self-neglect and guardianship is often handled in his jurisdiction (it tends to be extremely variable from place to place). You can report him to Adult Protective Services if you’re truly concerned; what they’ll do is quite variable.

You could also try contacting your local Area Agency on Aging to see what they recommend. Local geriatric care managers and/or elderlaw attorneys may also be good sources of information.

Basically, there is no easy way to intervene. I would recommend starting by learning more about what it would take for you — or someone else — to be able to override his choices, and that will be very dependent on how things are done in his area.

Last but not least, remember that you don’t necessarily have to hold yourself responsible for the outcomes in his life. You should try to help and you should try to be there for him, but it’s often not possible to control all the outcomes and sometimes we have to accept that people we love made choices that resulted in worse outcomes for themselves.

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